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Home , Amniotic fluid

Postpartum Complications

Paul Barter, FNP, EMT-P or Postnatal period

• The period beginning immediately after the of a child and extending for about six weeks World Health Organization (WHO)

• describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies ▫ most deaths occur during the postnatal period ▫ a time in which the mother's body, including hormone levels and uterus size, returns to a non- pregnant state  scientific literature, the term is abbreviated to Px, where x is a number  day P2 Common Postpartum Complications

• Hemorrhage • Perineal pain • Hemorrhoids and Constipation • Breast Problems ▫ Mastitis ▫ Swollen breasts ▫ Clogged ducts • Infections • Urinary incontinence Hemorrhage Definition and Incidence • Leading cause of maternal morbidity and mortality in the US and worldwide • Life-threatening event with little warning ▫ Loss of > 500 ml after vaginal delivery ▫ Loss of > 1,000 ml following c-section • Classification {in respect to birth} ▫ Early / Acute or Primary  With 24 hours of birth ▫ Late or Secondary  >24 hrs but < 6 weeks PPH - Causes

• ▫ Marked hypotonia of the uterus ▫ Leading cause of PPH ▫ 1:20 • Associated with ▫ High parity ▫ Multifetal ▫ Traumatic births ▫ Use of Magnesium Sulfate ▫ Rapid or prolonged labor ▫ Use of Pitocin for labor induction PPH - Causes

• Lacerations of the Genital Tract ▫ Cervix; ; perineum • Retained ▫ Very common in very preterm births (20 to 24 weeks) • Inversion of the Uterus ▫ Potentially life threatening  1 in 2,000 to 2,500 births ▫ Contributing factors  Fundal implantation of placenta  Vigorous fundal pressure  Excessive traction applied to the cord  Uterine atony PPH Hemorrhage Treatment

• Goal ▫ Prevent adverse sequela ▫ Restoring circulating blood volume ▫ Treat the cause of hemorrhage • Oxygen ▫ High concentration  Non-rebreather • IV Fluids ▫ Crystalloids ▫ Colloids ▫ Blood transfusion • ECG Monitoring Risk Factors for PPH

• Overdistended uterus • Coagulation disorders ▫ Large ▫ idiopathic thrombocytopenic purpura ▫ Multiple  Autoimmune - platlets ▫ Von Willebrand Disease • Anesthesia and analgesia  Type of hemophilia – Factor VIII deficiency Previous h/o uterine atony  Most common congenital clotting defect • ▫ Disseminated intravasuclar coagulation • High parity  Pathologic form of clotting and consumes platelets, fibrinogen, factor V and VIII • Prolonged labor, oxytocin-  Abruptio placenta  Amniotic fluid induced labor  Dead fetus syndrome  Severe preeclampsia • Lacerations of birth canal  Septicemia Ruptured uterus  Cardiopulmonary arrest •  hemorrhage • Inversion of the uterus • • Retained placental fragments • Placenta previa Trauma during labor and birth • • MgSO4 administration during ▫ Forceps-assisted birth or postpartum period ▫ Vacuum-assisted births • Endometritis ▫ Cesarean birth Perineal Pain - Region between the vagina and rectum - Experiences the most stretching and bruising during delivery - Episiotomy site Hemorrhoids and Constipation - Results in discharge of blood along with painful defecation Resolves spontaneously within few weeks Breast Problems - Mastitis - infection secondary to bacteria gaining entry into breast from babys mouth, dirty clothing - Swollen Breasts - engorged with milk - Clogged ducts - result of small clogs in ducts through which milk is passed out Common Postpartum Complications [con’t] • Perineal Pain ▫ Region between the vagina and rectum ▫ Experiences the most stretching and bruising during delivery ▫ Episiotomy site • Hemorrhoids and Constipation ▫ Results in discharge of blood along with painful defecation  Resolves spontaneously within few weeks • Breast Problems ▫ Mastitis  Discussed later - Swollen Breast  Engorged with milk - Clogged ducts  result of small clogs in ducts through which milk is passed out Common Postpartum Complications [con’t] • Infections ▫ Endometritis  Most common  Begins as localized infection at the placental site but can spread to entir ▫ Increase incidence after C-section  Signs/symptoms  Fever >38 degrees C [100.4]  Chills; increased HR; anorexia; nausea; fatigue; lethargy  Pelvic pain; uterine tenderness; foul-smelling lochia ▫ Wound infections  From C-section; episiotomy; repaired laceration site  Signs/symptoms  Erythema; edema; warmth; tenderness; seropurulent drainage; wound separation ▫ Mastitis  Affects about 1% of women, most of whom are first-time mothers breastfeeding  Almost always unilateral developing well after milk has established  Typically s.aureus transmitted via nipple  Signs/Symptoms  Chills; fever; malaise; local breast tenderness; redness; swelling; axillary adenopathy may occur Postpartum Complications [Infections] ▫ Urinary tract  Occur in 2% to 4% of postpartum woman  Risk factors  Urinary catheterization; frequent pelvic exams; epidural anesthesia; genital tract injury; history of UTI’s; cesarean birth ▫ Urinary Incontinence  Typically results from stress incontinece  Increase incidence/frequency with parity  Effects >23% of woman Other Postpartum Complications

• Post partum depression • Sheehan’s Syndrome • • Peripartum cardiomyopathy Post Partum Depression

• Etiology ▫ Unclear, may be biologic, psychologic, situational or multifactoral • Incidence ▫ About 25-85% of women will experience postnatal blues, only 7-17% will develop clinical depression  In the United States, is one of the leading causes of the murder of children <1 yr old which occurs in about 8 per 100,000 births Post Partum Depression

• Risk factors ▫ Prenatal depression/anxiety ▫ Low self-esteem ▫ Stress of ▫ Life stress ▫ Lack of social support ▫ Marital relationship problems ▫ History of depression ▫ “difficult” temperament ▫ Postpartum blues ▫ Single status ▫ Low socioeconomic status ▫ Unplanned or unwanted Post Partum Depression

• Controversial ▫ Multiple repeated mega-studies have not linked hormonal changes with postpartum depression. Concluded that it is a myth that hormonal changes lead to depression  Symptoms of preexisting mental illness exists  Exacerbated by fatigue, change in routine Other Postpartum Complications Sheehan’s Syndrome

• Sheehan’s Syndrome ▫ Postpartum hypopituitarism caused by ischemic necrosis due to blood loss and hypovolemia during and after . ▫ Rare complication of pregnancy • Hypertrophy and hyperplasia of prolactin cells causes enlargement of the anterior pituitary, without a corresponding increase in blood supply. ▫ Secondly, the anterior pituitary is supplied by a low pressure portal venous system  When affected by hemorrhage or hypotension leads to ischemia of the pituitary regions leading to necorsis  Posterior pituitary is usually not affected due to its direct arterial supply • Complications ▫ Since the anterior pituitary is damaged and loses the cells that normally secrete hormones  Prolactin - stimulates lactation  ADH - stimulates kidneys to reabsorb water  TSH - stimulates the thyroid  Cortisol - allows the body to survive in times of severe physical stress, such as when one is sick, and helps other hormones keep blood sugar levels elevated  Without these hormones, their respective jobs are not performed, and the signs and symptoms of pituitary damage ensue Sheehan’s Syndrome

• Signs/Symptoms ▫ Agalactorrhea (absence and/or difficulties with lactation) ▫ Amenorrhea or oligomenorrhea after delivery ▫ May be asymptomatic, and the diagnosis is not made until years later, with features of hypopituitarism:  Hypothyroidism  Tiredness; intolerance to cold; constipation; weight gain; hair loss; slowed thinking; slowed heart rate and low blood pressureAdrenal insufficiency [Addison’s Disease]  Adrenal Insufficiency [Addison’s disease]  Fatigue; weight loss; hypoglycemia; anemia; hyponatremia  Gonadotropin deficiency  Amenorrhea; oligomenorrhea; hot flashes; decreased libido  Growth hormone  Many vague symptoms including fatigue and decreased muscle mass Amniotic Fluid Embolism

• A rare childbirth emergency ▫ Amniotic fluid, fetal cells, hair or other debris enters the mother's blood stream via the placental bed of the uterus and triggers an allergic-like reaction ▫ This reaction then results in cardiorespiratory collapse and massive hemorrhaging ▫ First formally characterized in 1941  rare (between 1 in 8000 and 1 in 80,000 deliveries)  fifth most common cause of maternal mortality in the world Amniotic Fluid Embolism

• Some evidence shows that it may be associated with ▫ abdominal trauma or ▫ A 2006 study showed that the use of drugs to induce labor, such as misoprostol [Cyctotec], nearly doubled the risk ▫ Maternal age of 35 years or older ▫ Caesaren or instrumental vaginal delivery ▫ ▫ Cervical laceration ▫ ▫ Placenta previa or abruption ▫ ▫ Amniotic Fluid Embolism

• There is no specific treatment for amniotic fluid embolism • Initial emergency management is the same as for any other cause of sudden maternal collapse ▫ cardiovascular and respiratory resuscitation and correction of the coagulopathy • However, newer research with animal models suggest that significant embolism of any material is followed by: ▫ platelet degranulation ▫ pulmonary hypertension due to serotonin and thromboxane ▫ systemic hypotension due to vagal stimulation. • Armed with this knowledge, several women have survived and regained a pulse immediately after ondansetron [Zofran], metoclopramide [Reglan], atropine and ketorolax [Toradol] were administered. Peripartum cardiomyopathy

• Form of dilated cardiomyopathy • Defined ▫ a deterioration in cardiac function presenting typically between the last month of pregnancy up to 6 month postpartum • Etiology ▫ Unknown ▫ Incidence  1 in 1,300 to 4,000 live births  can occur in any woman of any racial background, at any age during reproductive years, and in any pregnancy ▫ Researchers are investigating  cardiotropic viruses  Autoimmunity or immune system dysfunction  Toxins that serve as triggers to immune system dysfunction  Micronutrient or trace mineral deficiencies  genetics Peripartum cardiomyopathy

• Pathophysiology ▫ Like other forms of dilated cardiomyopathy  heart muscle cannot contract forcefully enough to pump adequate amounts of blood for the needs of the body's vital organs  involves systolic dysfunction of the heart with a decrease of the LVEF  with associated CHF  increased risk of atrial and ventricular arryhtmias  Thromboembolism  Sudden cardiac death Peripartum cardiomyopathy

• Signs/symptoms ▫ Orthopnea ▫ Dyspnea ▫ Pitting edema ▫ Nocturia ▫ Excessive weight gain ▫ Palpitations ▫ S3 gallop; murmurs of MR and TR ▫ Liver failure ▫ Embolus ▫ Stoke ▫ AMI Peripartum cardiomyopathy

• Early detection and treatment ▫ Higher rates of recovery ▫ Decreased morbidity and mortality • Treatment ▫ Similar to CHF  Diuretics  Beta blockers  ACE-I  Anticoagulation if EF <35%  LVAD  Transplant Peripartum cardiomyopathy Prognosis

• Recent studies indicate that with newer conventional heart failure treatment survival rate is very high at 98% ▫ >50% of PPCM patients experience complete recovery of heart function (EF 55% or greater ▫ Almost all recovered patients are eventually able to discontinue medications with no resulting relapse and have normal life expectancy • It is a misconception that hope for recovery depends upon improvement or recovery within the first six to 12 months. ▫ Many women continue to improve or recover even years after diagnosis with continued medicinal treatment ▫ Once fully recovered, if there is no subsequent pregnancy, the possibility of relapse or recurrence of heart failure is minimal • Subsequent pregnancy should be avoided when left ventricular function has not recovered and the EF is lower than 55% • A significant study reports that the risk for recurrence of heart failure in recovered patients as a result of subsequent pregnancy is approximately 21% or better ▫ In any subsequent pregnancy, careful monitoring is necessary ▫ If relapse occurs, conventional treatment should be resumed Peripartum cardiomyopathy